International Journal of Medicine Research International Journal of Medicine Research ISSN: 2455-7404 www.medicinesjournal.com Volume 3; Issue 1; January 2018; Page No. 59-65 Acute cholangitis: Etiology, pathogenesis, classification, diagnosis and surgical tactics (Literature review) Ismoil Arziev1, Ulugbek Sherbekov2, Djalolov Davlatshokh3, Jaxongir Voxidov4, Firuza Kurbaniyazova5 1, 3, 4, 5 Samarkand State Medical Institute, Department of Surgical Diseases Samarkand city, Uzbekistan 2 Samarkand State Medical Institute, Department of Department of General Surgery, Samarkand city, Uzbekistan Abstract According to the literature, modern data on the etiology, pathogenesis, clinic, diagnosis, treatment and prevention of acute cholangitis and biliary sepsis are analyzed in the complication of cholelithiasis. Acute purulent cholangitis and biliary sepsis are different manifestations of the infectious and inflammatory process that occurs locally and systemically. Postoperative lethality ranges from 13 to 60%. Many issues of pathogenesis, treatment and prevention of these pathological processes are not completely resolved and need further study. Keywords: choledocholithiasis, acute cholangitis, detoxification, plasmapheresis Introduction maintain a certain tone of the body's immune system due to The frequency of purulent complications of inflammatory the reaction of intestinal lymph nodes and fixed liver diseases of the biliary tract, despite the close attention of macrophages to them [2, 12, 18]. researchers to this problem, remains highly relevant. The When the pressure is raised to 300 - 450 mm. water. art. there inflammatory process in this localization is characterized not is cholangiogenic and cholangiolymphatic reflux, as a result of only by the local purulent-destructive process, but also by which bacteria and endotoxin from the infected bile enters the systemic disorders that quickly lead to severe endogenous systemic circulation. Also, with cholestasis, the function of intoxication and severe organ dysfunction. Such a condition is Kupffer cells is disrupted and their phagocytic activity most often considered as a cholangitis, the severity of its decreases. Against this background, when the syndrome of morphological and clinical manifestations is very diverse [9, 24]. achiolia develops, the permeability of the intestinal wall Mortality, according to various authors, is still high, reaching increases for bacteria and endotoxin, and their concentration up to 30%. In the elderly, burdened with severe concomitant increases in the blood of the portal vein [7, 12, 18, 21]. diseases, acute cholecystitis, complicated purulent cholangitis, Thus, in two ways - through the biliary system and through represents the most difficult problem diagnosis and treatment the portal vein - endotoxin and bacteria enter the central vein [12, 18]. In this case, choledocholithiasis in combination with of the sinusoid, from where they enter the central bloodstream. stenosis of the terminal section of choledoch causes the most This causes the development of an immune reaction, severe violation of bile passage and is the most common cause accompanied by the release of cytokines, prostaglandins, of purulent cholangitis [17, 26]. peptides with vasoactive properties and causing a Often, the cause of obstruction can also be benign stricture of characteristic vascular and general reaction. the bile duct and stricture of the biliodigestive anastomosis [18, There is no single generally accepted classification of 33]. cholangitis to date [2, 4, 18]. However, most authors adhere to Cholangitis can act as a complication of reconstructive the following division of purulent cholangitis: three forms of operations on the bile ducts, for example, when applying an purulent cholangitis - acute, acute recurrent and chronic [1, 26]. anastomosis of choledochus or a common hepatic duct with a Since most often the course of the disease is caused by small intestine with an insufficiently wide opening or with the purulent complications, they distinguish purulent cholangitis development of cicatricial stenosis of the anastomosis [2, 3, 7, 9, without purulent complications with septicemia and 21]. The cause of cholangitis can also be internal biliary fistula septicopyemia. The following forms of purulent cholangitis - in most patients with Mirizzi syndrome, cholangitis is are distinguished from the degree of lesion of the liver detected [19, 27]. parenchyma: with lesion of the liver parenchyma, with After analyzing the results of surgical treatment of 56 patients pericholangitis, with lesion of portal tracts, biliary cirrhosis of with chronic obstructive pulmonary disease, complicated the liver. By the nature of inflammation, catarrhal, purulent, Mirizzi syndrome, Z.B. Kurbaniyazov et al. (2011) offer a fibrotic, fibro-purulent, fibro-ulcerative, gangrenous differentiated treatment approach depending on the type of cholangitis is isolated. By type of causative agent, cholangitis this pathology and the nature of the inflammatory process of can be aerobic, anaerobic and mixed. According to the clinical the bile duct [32]. course, the following forms of cholangitis are suggested: 1. According to the ideas of other authors, the other way getting acute cholangitis with a favorable course; 2. Acute purulent bacteria in the bile - it is their arrival is, in the portal cholangitis; 3. septic form of acute cholangitis; 4. chronic circulation from the small intestine. Normally, these bacteria cholangitis with subclinical course; 5. chronic cholangitis with 59 International Journal of Medicine Research septic course [2, 18, 26]. form of cholecystitis, cholecystolithiasis and signs of bile The results of treatment of diseases complicated by the onset hypertension is close to 100%. The ability of the method to of purulent cholangitis primarily depend on the timely and determine the level and cause of obstruction of the biliary tract accurate diagnosis of the nature of jaundice, the level and is from 22 to 88% [2, 8, 18]. Ultrasound as non-invasive, fast- cause of obstruction of the bile duct [32]. So y a number of performing and easily tolerated by patients is suggested to be patients with purulent cholangitis initially develop severe CNS used in all patients with suspected purulent cholangitis. Signs disorders, and the classical triad Charcot manifested itself in of cholangitis in ultrasound - a thickening of the wall of later terms of the disease. Sometimes there is no pronounced choledoch, the presence in its lumen of a parietal sediment and temperature reaction, no leukocytosis, and the operation is echopositive inclusions ranging in size from 2 to5 mm without difficult cholangitis with multiple liver abscesses. There are acoustic shade (flakes of pus, fibrin films, putty) are cases when acute purulent cholangitis stimulated such diseases determined in no more than 18% of cases. Together with the of the abdominal cavity organs as acute cholecystitis, acute stress tests, it is possible to determine the functional state of pancreatitis, perforated ulcer of the stomach and duodenum. the hepatic tissue and its reserve capabilities in combination The diagnosis does not cause doubt only in those cases when with the test samples [29, 37]. its clinical manifestations are objectively confirmed by Computer tomography is a highly informative noninvasive complete obstruction of the bile ducts [5, 29]. method for diagnosing liver, bile duct and pancreas pathology. Along with the characteristic clinical picture of the disease, an With its help, you can determine the biliary hypertension and important role in the diagnosis of acute cholangitis belongs to clarify the cause of obstruction of the biliary tract. a number of biochemical parameters of blood serum (total Unexpended intrahepatic bile ducts with computed bilirubin and its fractions, ALAT, ASAT, alkaline tomography on "native scans" are not normally visible. phosphatase, gamma-glutamyltranspeptidase, etc.) [3, 14]. In the However, KT has a number of drawbacks. These include: the laboratory study of peripheral blood, pronounced leukocytosis need for X-ray exposure, invasiveness due to the need for with a leftward shift, thrombocytopenia, a high degree of ESR intravenous or intra-arterial administration of contrast agents; increase, anemia increases. Bilirubin in acute purulent limited use in patients with allergic reactions to iodine (use of cholangitis is usually in the range of 85 - 120 μmol / L, but iodine-containing contrast agents); the presence of a "step" of occasionally there is hyperbilirubinemia up to 300 μmol / l, the tomograph makes the procedure dependent on the choice which usually indicates the severity of purulent cholangitis. of the program; the impossibility of characterizing the motion There is always an increase in the activity of alkaline and pulsation of structures. This method is of special value in phosphatase [27]. the detection of cholangiogenic liver abscesses [18, 24]. The frequency of bacteremia is 40 - 60%. With a positive Available single reports on the use of spiral computed result of blood culture, the isolated flora coincides with strains tomography in the diagnosis of extrahepatic biliary tracts obtained from bile. Bacteriobiology occurs in 85 - 100% of special advantages of this method over the conventional CT cases, with more often (60-70%) in the association of technique have not been revealed [36]. microorganisms, less often (15-25%) in the form of Magnetic resonance imaging (MRI) is a new technique